rubyedward
Forum Elite
Topics: 12
Posts: 197
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hi guys, all q don't necc EM. but to save time for browsing i put nonEM, EM all together. sorry for the mess.
1) 45 y/o truck driver involved in MVA, resulted in closed hesd injury, presents to ER, he was intubated at the field and on arrival he’s oxygenated well with assisted ventilation, has normal BP & moderate tacchycardia. GCS = 7, pupils are equal & slowly reactive. After stabilization, a head CT is done which shows small SAH & Rt. frontal lobe contusion. Abd. CT is normal. The optimal Mx of this px ICP is :<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
a- fluid restriction, hyperventilation, IV steroids
b- fluid restriction, hyperventilation & ventriculostomy
c- fluid restriction & osmotic diuresis
d- normovolemia, normocarbia & ventriculostomy
e- craniectomy
2) A 70 y/o man with hx of HTN & mild CHF ( which was controlled with digoxin & diuretics ) is admitted for an AAA repair. To faciliate perioperative Mx, a swan- ganz cath. is inserted in the OR. During a first few hours post op he’s noted to have BP= 140/70, HR=110, flat neck veins, pulmonary arterial wedge pressure of 9 mm/hg & poor urine output.
1- The next best step of Mx is :
a- IV furesmide
b- Bolous IV crystalloid
c- Dopamine infusion
d- Nitroprusside infusion
e- IV digoxin
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Several hours after this intervention, BP=150/85, HR=90, neck veins are distended, pulmonary arterial wedge pressure is 17 and urine output is still low.
2- At this point, Mx should be:
a- IV furesmide
b- Bolous IV crystalloid
c- Dopamine infusion
d- Nitroprusside infusion
e- IV digoxin
3) 70 y/o man presents with back pain & difficulty urination. On DRT, he has a hard, irregularenlarged prostate. PSA is elevated & osteoblastic lesions of vertebral column & pelic bones are noticed. The Tx of choice is:
a- radical prostatectomy
b- transurethral prostatectomy
c- cytotoxic chemotherapy
d- hormonal manipulation
e- radiotherapy
4) A 75 y/o woman is brought to ER from nursing home for jaundice & mental confusion. The nusrsing home notes states that she became less responsive & developed jaundice over the last 2 wks. PMH is positive for HTN, DM & prior colon resection for colon cancer at age 55. V/S : BP= 100/60, HR= 110, T= 101.5, P/E shows no response to verbal command but withdraws to pain, a mild jaundice with tenderness in epigastrium & RUQ. What’s the most likely Dx?
a- Hepatitis A
b- Biliary stricture
c- Choledochal cyst
d- Liver metastasis
e- Choledocholithiasis
f- Cirrhosis
g- Pancreatitis
5) A 66 y/o woman who has previously been healthy undergoes emergency surgery for a ruptured AAA. Intraoperatively she requires 8 units of packed red blood cells to maintain her blood pressure and hematocrit. After surgery she is hemodynamically stable. On the third post-op day she appears jaundiced, but abdominal examination is unremarkable and she is afebrile. Lab results:
Total serum BR=8.3 mg/dL (direct= 6.3 mg/dL)
Serum Alk. Ph.= 360 U/L
Serum AST = 51 U/mL
The most likely explanation for the woman's jaundice is
A: a stone in the common bile duct
B: halothane hepatitis
C: posttransfusion hepatitis
D: acute hepatic infarct
E: benign intrahepatic cholestasis
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| Springd
Forum Senior
Topics: 5
Posts: 62
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hey ruby... good Q's
1. Let me go revise head injuries
2. b
the second one, a
3.d
4.d
5.c
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| rubyedward
Forum Elite
Topics: 12
Posts: 197
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good springd. try again for 2b, 4, 5.
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| rubyedward
Forum Elite
Topics: 12
Posts: 197
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1. answer is d- normovulemia, normocarbia & ventriculostomy<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
The principle of Mx of closed head injury is to maintain cerebral perfusion & oxygenetaion to prevent secondary brain damage. Remember this formula:
CPP ( cerebral perfusion pressure )= mean BP – ICP, So normal CPP requires adequate circulating blood volume with maintanace of normovolemia. Early ventriculostomy is beneficial to permit controlled drainage of CSF to maintain normal CPP.
Note: Fluid restriction, hyperventilation, hypercarbia ( -- > vasodialation & inc. ICP ) should be avoided.
2. Answers are: 1- b, 2-d
In the initial post op period, px has a low pwp & poor urine output, renal perfusion is compromised by hypovolemia with subsequent inadequate preload & decreased cardiac output. So at this time IV fluid resuscitation is appropriate.
After fluid bolous px developes extended neck veins & elevated pwp, indicating biventricular dysfunction with increased left end diastolic pr. & increased left ventricular end systolic volume. CO is low & urine outpout is not improved, so with px hx all scenario is due to increased afterload which can be reduced by nitroprusside infusion.
[font="Times New Roman">4. Answer is e- choledocholithiasis. <?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /">
Common bile duct stones may be the cause of acute bile duct obstruction without warning resulting in jaundice, pain & sepsis. The sepis may manifest as fever, hypotestion & altered mental status. [/font]
5. The answer is E- Benign intrahepatic cholestasis
Benign post-op intrahepatic cholestasis can develop as a consequence of major surgery for a catastrophic event in which hypotension, extensive blood loss into tissues, and massive blood replacement are notable. Factors contributing to jaundice include the pigment load from transfusions, decreased liver function resulting from hypotension, and decreased renal bilirubin excretion caused by tubular necrosis. Jaundice becomes evident on the second or third postoperative day, with bilirubin levels (mainly levels of conjugated bilirubin) peaking by the tenth day. Serum Alk. Ph. concentration may be elevated up to tenfold, but AST level is only mildly elevated. Hepatitis, choledocholithiasis, and hepatic infarct are unlikely diagnoses in the absence of abdominal tenderness, fever, or a significant rise in AST levels. The incubation period of posttransfusion hepatitis is 7 weeks, making this diagnosis unlikely.
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| phuluong2k
Forum Fanatic
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Posts: 2,008
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In qestion 2.2 why the choice is not Furosemide ?
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| dr79
Forum Senior
Topics: 17
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ya tats exactly wt i wana ask....y not frusemide??
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| bobby
Forum Guru
Topics: 136
Posts: 569
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i am very convinced that in 2.2, the ans should be furosemide.
i don't think given nitroprusside will change the pt's situation that much. he has been anuric for hours with evident signs of fluid overload. so furosemide should be the right ans.
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| rubyedward
Forum Elite
Topics: 12
Posts: 197
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well yes, thats wat i first thought, but the correct answer is nitroprusside.....i can only imagine that the pt. developed very high pulm wedge pressure and distended neck veins and relatively high BP compare to 2.a and his renal perfussion is not adequate (very small portion of blood supply to kidneys owing to high pressure like dr. goljan gave eg. of strong water tunnel with high pressure), so nitroprusside can do a better and quicker job than furasemide to lower pressure down.
Edited by rubyedward on 07/06/05 - 03:23 AM
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| mdwannabe
Forum Guru
Topics: 37
Posts: 1,133
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where did these come from? Some of them seem fishy. The first thing that I wiould be thinking of in the case of low urinal output with moderately high pressure and high PR in pt post AAA is ARF due to low perfusion (volume depletion) due to Sx. So... fluid first...then Lasix if pressure still high. Nitroprusside will dialate both arterioles and venules thus decresing GFR further ,making ARF worse.
Edited by mdwannabe on 07/10/05 - 03:58 PM
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